Early Transjugular Intrahepatic Portosystemic Shunt Research Articles

Predicting Portal Pressure Gradient in Patients with Decompensated Cirrhosis: A Non-invasive Deep Learning Model.

A high portal pressure gradient (PPG) is associated with an increased risk of failure to control esophagogastric variceal hemorrhage and refractory ascites in patients with decompensated cirrhosis. However, direct measurement of PPG is invasive, limiting its routine use in clinical practice. Consequently, there is an urgent need for non-invasive techniques to assess PPG. To develop and validate a deep learning model that predicts PPG values for patients with decompensated cirrhosis and identifies those with high-risk portal hypertension (HRPH), who may benefit from early transjugular intrahepatic portosystemic shunt (TIPS) intervention. Data of 520 decompensated cirrhosis patients who underwent TIPS between June 2014 and December 2022 were retrospectively analyzed. Laboratory and imaging parameters were used to develop an artificial neural network model for predicting PPG, with feature selection via recursive feature elimination for comparison experiments. The best performing model was tested by external validation. After excluding 92 patients, 428 were included in the final analysis. A series of comparison experiments demonstrated that a three-parameter (3P) model, which includes the international normalized ratio, portal vein diameter, and white blood cell count, achieved the highest accuracy of 87.5%. In two distinct external datasets, the model attained accuracy rates of 85.40% and 90.80%, respectively. It also showed notable ability to distinguish HRPH with an AUROC of 0.842 in external validation. The developed 3P model could predict PPG values for decompensated cirrhosis patients and could effectively distinguish HRPH.

Recompensation after TIPS reduces the incidence of hepatocellular carcinoma and increases survival in patients with cirrhosis.

It has been described that recompensation can improve prognosis in patients with cirrhosis. However, recompensation after transjugular intrahepatic portosystemic shunt (TIPS) has not been studied. We evaluated the impact of recompensation after TIPS on the risk of hepatocellular carcinoma (HCC) and death, and we compared it with compensated cirrhosis patients. An observational study of consecutive patients with cirrhosis undergoing TIPS between 2008 and 2022 was performed. Baveno VII definition of recompensation was used including patients with or without diuretics/Hepatic encephalopathy prophylaxis. A prospective cohort of consecutive compensated cirrhosis patients was used for comparison. Overall, 208 patients with cirrhosis were included, 92 compensated and 116 decompensated who underwent TIPS. After 1 year, 24% achieved recompensation. Liver function (MELD 12 ± 5 vs. 15 ± 6; p = .049), LDL-cholesterol (97 mg/dL vs. 76 mg/dL, p = .018), white cell count (7.96 × 109/dL vs. 6.24 × 109/dL, p = .039) and platelets (129 × 109/dL vs. 101 × 109/dL, p = .039) were associated with recompensation. Recompensation was associated with a reduction in the risk of HCC (p = .020). Multivariable analysis showed that this risk was significantly higher in non-recompensated patients (p = .003) but no differences were observed in recompensated compared with compensated patients (p = .816). Similarly, decompensated patients presented lower survival rates (p = .011), while no differences were observed between recompensated and compensated patients (p = .677). Recompensation after TIPS has a clear impact on the incidence of HCC and death, with a similar prognosis than patients with compensated cirrhosis. Liver function is associated with recompensation, suggesting the importance of considering early TIPS in patients with indication.

Procalcitonin as a Biomarker for Early Trans-jugular Intrahepatic Porto-Systemic Shunt (TIPS) Stent Occlusion Prediction in Patients with Budd Chiari Syndrome

Procalcitonin as a Biomarker for Early Trans-jugular Intrahepatic Porto-Systemic Shunt (TIPS) Stent Occlusion Prediction in Patients with Budd Chiari Syndrome

Outcome of Transjugular Intrahepatic Portosystemic Shunt in Patients with Cirrhosis and Refractory Hepatic Hydrothorax: A Systematic Review and Meta-analysis.

Background Around 5% of patients with cirrhosis of the liver develop hepatic hydrothorax (HH). For patients with refractory HH (RHH), transjugular intrahepatic portosystemic shunt (TIPS) has been investigated in small studies. Hence, the present meta-analysis aimed to summarize the current data on the outcome of TIPS in patients with RHH. Methods From inception through June 2023, MEDLINE, Embase, and Scopus were searched for studies analyzing the outcome of TIPS in RHH. Clinical response, adverse events (AEs), mortality, and shunt dysfunction were the primary outcomes assessed. The event rates with their 95% confidence interval were calculated using a random-effects model. Results A total of 12 studies ( n = 466) were included in the final analysis. The pooled complete and partial response rates were 47.2% (35.8-58.5%) and 25.5% (16.7-34.3%), respectively. The pooled incidences of serious AEs and post-TIPS liver failure after TIPS in RHH were 5.6% (2.1-9.0%) and 7.6% (3.1-12.1%), respectively. The pooled incidences of overall hepatic encephalopathy (HE) and severe HE nonresponsive to standard treatment after TIPS in RHH were 33.2% (20.0-46.4%) and 3.6% (0.4-6.8%), respectively. The pooled 1-month and 1-year mortality rates were 14.0% (8.3-19.6%) and 42.0% (33.5-50.4%), respectively. The pooled incidence of shunt dysfunction after TIPS in RHH was 24.2% (16.3-32.2%). Conclusion RHH has a modest response to TIPS in patients with cirrhosis, with only half having a complete response. Further studies are required to ascertain whether early TIPS can improve the outcome of patients with cirrhosis and HH.

The Value of Neutrophil-to-Lymphocyte Ratio in Predicting Mortality After Transjugular Intrahepatic Portosystemic Shunt Placement.

The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS). A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality. The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356). NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.

Comparative efficacy of early TIPS, Non-early TIPS, and Standard treatment in patients with cirrhosis and acute variceal bleeding: a network meta-analysis.

Cirrhosis is a chronic disease characterized by chronic liver inflammation and diffuse fibrosis. A combination of vasoactive drugs, preventive antibiotics, and endoscopy is the recommended standard treatment for patients with acute variceal bleeding; however, this has been challenged. We compared the effects of early transjugular intrahepatic portosystemic shunt (TIPS), non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. The present network meta-analysis was conducted in accordance with the criteria outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Assessing the methodological quality of systematic reviews guidelines. The review has been registered with the International Prospective Register of Systematic Reviews. The PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and World Health Organization-approved trial registry databases were searched for randomized controlled trials (RCTs) evaluating early TIPS, non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. Twenty-four RCTs (1894 patients) were included in the review. Compared with standard treatment, early TIPS [odds ratio (OR), 0.53; 95% credible interval (Cr), 0.30-0.94; surface under the cumulative ranking curve (SUCRA), 98.3] had a lower risk of all-cause mortality (moderate-to-high-quality evidence), and early TIPS (OR, 0.19; 95% CrI, 0.11-0.28; SUCRA, 98.2) and non-early TIPS (OR, 0.30; 95% CrI, 0.23-0.42; SUCRA, 1.8) were associated with a lower risk of rebleeding (moderate-to-high-quality evidence). Early TIPS was not associated with a reduced risk of hepatic encephalopathy, and non-early TIPS (OR, 2.78; 95% CrI, 1.89-4.23, SUCRA, 0) was associated with an increased incidence of hepatic encephalopathy (moderate-to-high-quality evidence). There was no difference in the incidence of new or worsening ascites (moderate-to-high-quality evidence) among the three interventions. Based on the moderate-to-high quality evidence presented in this study, early TIPS placement was associated with reduced all-cause mortality [with a median follow-up of 1.9 years (25th-75th percentile range 1.9-2.3 years)] and rebleeding compared to standard treatment and non-early TIPS. Although early TIPS and standard treatment had a comparable incidence of hepatic encephalopathy, early TIPS showed superiority over non-early TIPS in this aspect. Recent studies have also shown promising results in controlling TIPS-related hepatic encephalopathy. However, it is important to consider individual patient characteristics and weigh the potential benefits against the risks associated with early TIPS. Therefore, we recommend that clinicians carefully evaluate the patient's condition, considering factors such as severity of variceal bleeding, underlying liver disease, and overall clinical status, before making a treatment decision. Further well-designed RCTs comparing early TIPS with non-early TIPS are needed to validate these findings and provide more definitive guidance.

Intravascular Ultrasound for Transjugular Intrahepatic Portosystemic Shunt Creation: "TIPS" and Tricks.

Cirrhosis affects 4.5 million people in the United States.[1] Sequela of cirrhosis and portal hypertension include varices, which occur in up to 60 to 80% of cirrhotic patients and pose a bleeding risk of 25 to 35%[2]; refractory ascites, which occurs in 5 to 10% of patients[3]; recurrent hepatic hydrothorax, which occurs in 5 to 10% of cirrhotic patients[4]; and hepatic encephalopathy, which occurs in up to 45% of patients with cirrhosis.[5] Transjugular intrahepatic portosystemic shunt (TIPS) creation results in portal venous decompression and reduces mortality and morbidity associated with these portal hypertensive sequelae. There is a clear survival benefit with TIPS creation in patients at risk of variceal hemorrhage, including those who fail endoscopic banding, who are at high risk of pharmacologic or endoscopic treatment failure,[6] and who undergo early TIPS creation for secondary prophylaxis against bleeding.[7] [8] For those with refractory ascites and hepatic hydrothorax, resolution of fluid accumulation can be expected in 85%[9] and 82%, respectively.[10]

Emphasis on the prevention and treatment of hepatic vascular diseases

Portal hypertension, as a common and complex hepatic vascular disease, is a key pathophysiological link in many events of acute cirrhosis decompensation and the progression of multiple organ failure. The most effective measure to reduce portal hypertension is a transjugular intrahepatic portosystemic shunt (TIPS). Maintaining liver function, reducing complications, and improving patients' quality of life and survival time are positively impacted by early TIPS insertion. Patients with cirrhosis have a risk of portal vein thrombosis (PVT) that is 1 000 times higher than that of the normal population. Hepatic sinusoidal obstruction syndrome has a severe clinical course and a high mortality risk. The primary treatment approaches for PVT and HSOS are anticoagulation and TIPS. The innovative magnetic anastomosis vascular technique significantly shortens the anhepatic time and restores normal liver function in patients following liver transplantation.

Gender differences in esophageal variceal bleeding in the United States

Background and Aims Esophageal variceal bleeding is a common reason for hospitalization in patients with cirrhosis. The main objective of this study was to analyze the effects of gender differences on outcomes in hospitalizations related to Esophageal variceal bleeding in the United States. Methods A retrospective observational cohort study was performed using the National Inpatient Sample (NIS) database for all hospitalizations with a discharge diagnosis of esophageal varices with hemorrhage from 2016 to 2019. The primary outcome was in-hospital mortality, while secondary outcomes included rate of early endoscopy (defined as less than 1 day), AKI, blood transfusion, sepsis, ICU admission and TIPS (Transjugular Intrahepatic Portosystemic Shunt). We also compared the length of stay and total hospitalization charges. Results We identified a total of 166,760 patients with variceal bleeding of which 32.7% were females. In-hospital mortality was higher in males, 9.91%, compared to females, 8.31% (adjusted odds ratio (aOR): 0.88, p-value=.008, when adjusted for confounding factors). The odds of undergoing an EGD, length of stay, or total hospitalization charges did not differ between the two groups. Compared to men, women had lower odds of receiving TIPS (aOR = 0.83, p-value=.002). Conclusion Women hospitalised with esophageal variceal bleeding are at a lower risk of death compared to males. Further research is needed to elucidate the factors associated with this lower risk.

Practice patterns in endoscopic treatment for gastric varices: A Chinese survey

Gastric varices (GV), a common complication of liver cirrhosis, often cause serious consequences. However, the management of GV remains debated. In this study we aimed to explore the practice patterns of Chinese practitioners in GV treatment and discuss whether these patterns conform to the guidelines in China and around the world. Between October 2020 and January 2021, an online questionnaire was sent to doctors from different regions in China via WeChat. Data on the practice patterns for endoscopic treatment with and without a multidisciplinary discussion team (MDT) clinic for GV were analyzed. Questionnaires were collected from 241 practitioners from 29 provinces in China. Before endoscopic treatment, 100 (41.5%) of the practitioners arranged computed tomography angiography (CTA) examination. In endoscopic tissue adhesive (ETA) treatment, 183 (75.9%) of the practitioners chose ETA combined with lauromacrogol. Approximately one-fourth of all practitioners did not prescribe drugs to reduce portal pressure. Only 75 (31.1%) of physicians preferred using early transjugular intrahepatic portosystemic shunt (TIPS) for patients at a high risk of treatment failure for GV. Compared to those without MDT clinics, practitioners with MDT clinics more often chose early TIPS for high-risk patients (39.0% vs 18.9%, P=0.001). Treatment for GV differ across China. Practitioners with MDT clinics can better use assistant strategies such as CTA to evaluate the risk and efficacy. Further clinical studies are needed, and more guidelines and consensuses are warranted to standardize clinical practice for GV.

Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection.

This review summarizes indications and contraindications for implantation of transjugular intrahepatic portosystemic shunt (TIPS). Further, patient selection strategies are discussed. TIPS implantation is a highly effective treatment for portal hypertension. Main indications are ascites and variceal bleeding in patients with liver cirrhosis. There is growing evidence that early TIPS implantation after variceal bleeding is associated with an improved survival (preemptive TIPS).Preliminary data also suggest that an analogous concept of early TIPS implantation may be beneficial for patients with ascites. Further, well-selected patients with acute or chronic nonmalignant portal vein thrombosis can be effectively treated with TIPS implantation. In contrast, there is generally no recommendation for TIPS implantation in patients with hepatic veno-occlusive disease, noncirrhotic portal hypertension or prior before surgery to avoid complications of portal hypertension. Apart from evidence-based patient selection, the newly developed FIPS score can be an objective component in decision-making. Consideration of well-established indications and contraindications for TIPS implantation as well as concise patient selection criteria are essential for an optimal outcome after TIPS implantation.

Acute Variceal Bleeding Is It Only the Success of Hemostasis That Guarantees the Positive Outcome?

Acute variceal bleeding remains with a high mortality rate (around 15%). Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation, and antibiotic therapy. Effective resuscitation (blood transfusions, volume replacement) is essential to prevent complications. In case of failure - transjugular intrahepatic portosystemic shunt (TIPS) with appropriate indications and limitations related to the prognosis of the individual patient. Balloon tamponade or specially designed coated esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early TIPS should be the first choice in patients at high risk of treatment failure (Child-Pugh B with active bleeding or Child-Pugh C &lt; 14). This article discusses the latest advances in variceal bleeding management in line with current recommendations of the Baveno VI Consensus Conference.

Comparison of the Covered Self-Expandable Viatorr CX Stent with the Covered Balloon-Expandable BeGraft Peripheral Stent for Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation: a Single-Centre Retrospective Study in Patients with Variceal Bleeding.

This study compares the safety and efficacy of the ePTFE-covered self-expansible nitinol stent (VIATORR® Controlled Expansion, Gore, Flagstaff, USA) with the ePTFE-covered, balloon-expandable, metallic stent (BeGraft peripheral, Bentley, Hechingen, Germany) for the creation of the transjugular intrahepatic portosystemic shunt (TIPS). From September 2016 to December 2020, 72 consecutive patients receiving TIPS for acute variceal bleeding (rescue and early TIPS, n = 15) or for prophylaxis of variceal rebleeding (n = 57) were enrolled. The main contraindications were patients with vascular liver disease (portal vein thrombosis and Budd-Chiari syndrome). Forty patients (55.6%) received a Viatorr CX stent and 32 patients (44.4%) a BeGraft peripheral stent. Safety endpoints were technical and clinical adverse events and early deaths within 30days after TIPS implantation. Efficacy endpoints were rebleeding rates, recurrence of large varices requiring endoscopic band ligation, or TIPS revision. Groups receiving the Viatorr CX or BeGraft peripheral stent were comparable in all respects except the TIPS indication for acute variceal bleeding (5% vs. 25%, p = 0.015). All patients had a successful intervention, and the physical variables of stent implantation (intervention and fluoroscopy time, reduction of the portosystemic pressure gradient) as well as adjunctive embolization of varices were similar in both groups. Severe clinical complications (Viatorr CX: 5% vs. BeGraft peripheral: 3.1%, p = 0.692), post-TIPS hepatic encephalopathy (12.5% vs. 18.8%, p = 0.743) and death (5% vs. 0%, p = 0.793) were not different between Viatorr CX and BeGraft peripheral groups. With respect to efficacy, freedom from rebleeding and from variceal band ligation during follow-up (100% vs. 100%, p = 1.0), as well as the need for shunt revision (10.5% vs. 18.8%, p = 0.327), was comparable. Compared to the present gold standard, the Viatorr CX stent, the balloon-expandable BeGraft peripheral stent, showed similar results with respect to safety and efficacy.

Determinants of Re Bleeding and Mortality in Cirrhotic Patients after Variceal Bleeding

Background: Variceal bleeding (VB) is the most serious complication of liver cirrhosis and carries a high mortality rate. Methods: The retrospective analysis on 263 cirrhotic patients with variceal bleeding in Taipei Medical University Shuang Ho hospital from 2012 to 2018. Aim: determine determinants of re-bleeding and mortality. Results: Patients’ characters were median age (56 years), male (73.4%), HCC (28.1%), ascites (53.2%), portal vein thrombosis (PVT, 6.4%), mean MELD score (17.5); mean Child-Tourette-Pugh score (CTP=8.2) and active bleeding at endoscopy (44.8%). Variceal re-bleeding occurred 4.1% at day-five, 11.0% at week-six and 28.1% at year-one. CTP score&gt;7, MELD score&gt;16, bilirubin&gt;30mg/dL, hepatic encephalopathy and HCC predicted early and late re-bleeding. Old age, renal injury, active bleeding, albumin&lt;2.8 g/dL, ascites, bacterial infection and PVT determined early re-bleeding. The mortality after first VB was 3.8%, 14.1% and 25.8% at day-5, week-6 and year-1 respectively. Old age, CTP&gt;7, MELD&gt;16, renal injury, ascites, hepatic encephalopathy, bacterial infection and HCC were determined early and late mortality. Early variceal re-bleeding was associated with early mortality. Use of non-selective beta-blocker or variceal ligation reduced mortality at year-1 (Odds Ratio; OR 0.03 and OR 0.3) and combination therapy reduced early re-bleeding (OR 7.5). Conclusion: Re-bleeding and mortality rate after VB were substantially high in hepatic decompensation, renal injury, presence of HCC, PVT and infection. Early identification of variceal bleeding patients who are at substantially high risk would probably benefit from early trans-jugular intrahepatic portosystemic shunt or liver transplantation.

Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites.

Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT). We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35). Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden. Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to standard medical management and conventional TIPS, respectively.

Single-Centre Retrospective Training Cohort Using Artificial Intelligence for Prognostic Prediction of Encephalopathy, Mortality, and Liver Dysfunction after Early TIPS Creation.

Based on an artificial intelligence approach, this study attempted to establish prognostic models to predict 3-month overt hepatic encephalopathy (OHE) occurrence, 1-year mortality, and liver dysfunction for cirrhotic patients with acute variceal bleeding (AVB) treated with early transjugular intrahepatic portosystemic shunt (TIPS) creation. This retrospective study included patients treated with early TIPS between January 2016 and November 2019. Independent risk factors associated with occurrence of OHE within 3months, 1-year mortality, and liver dysfunction after early TIPS were identified using univariate and multivariate logistic analyses. Artificial neural network (ANN) models and prognostic nomograms based on the independent risk factors were established and validated internally. A total of 207 patients were included, with 33 (15.9%) experienced OHE within 3months after TIPS creation. The albumin-bilirubin grade (P = 0.015), age (≤ 65, > 65years) (P < 0.001), gender (P = 0.002), and alcoholic cirrhosis (P = 0.013) was identified as independent risk factors associated with 3-month OHE. Presence of portal vein thrombosis (P = 0.034) and model for end-stage liver disease score (P = 0.063) were identified as independent risk factors associated with 1-year mortality. The platelet-albumin-bilirubin grade (P = 0.041) and a history of hepatic encephalopathy (P = 0.018) were identified as independent risk factors associated with liver dysfunction after TIPS creation. Three ANN models and three nomograms were then established and validated with high accuracy. The ANN and nomogram models have potential to accurately predict early occurrence of OHE, mortality, and liver dysfunction after early TIPS creation for cirrhotic patients with AVB.

Updated strategies in the management of acute variceal haemorrhage.

This article reviews the most recent studies regarding the management of acute esophageal variceal haemorrhage. New randomized control trials and meta-analyses confirmed the role of early transjugular intrahepatic portosystemic shunt (TIPS) in the management of acute variceal haemorrhage in Child-Pugh C (10-13) and B patients with active bleeding. A recent randomized controlled trial focused on the duration of vasoactive therapy showed no difference between 2 and 5 days of octreotide. A randomized trial showed decreased use of blood products for the correction of coagulopathy using a thromboelastography-guided approach (vs. conventional parameters) as well as decreased bleeding rates when compared with standard of care. A meta-analysis found that for rescue of variceal bleeding, self-expanding metallic stents were more efficacious and safer than balloon tamponade. In addition, studies showed that Child-Pugh C patients and those with hepatic vein pressure gradient more than 20 were at the highest risk of treatment failure, while model for end-stage liver disease was highly predictive of in-hospital mortality. In patients with severe coagulopathy and uncontrolled bleeding, TEG-based transfusion strategies are recommended. Antibiotics should be used for all cirrhotic patients presenting with upper gastrointestinal bleeding, but should be tailored in accordance to local resistance patterns. Early TIPS for high-risk patients has been shown to have a significant survival benefit. Certain aspects of the management of variceal bleeding remain poorly studied such as the role of early TIPS in Child-B patients as well as strategies for rescue therapy in patients who are not TIPS candidates, and require further investigation.

Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival

Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation. A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n= 1,496) and a validation set (20% of study patients; n= 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n= 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors. Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation. The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation. Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding.

Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P<0.001] and 0.556 [P<0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

Study of portal venous pressure gradient to predict high-hepatic encephalopathy-risk population post TIPS

Transjugular intrahepatic portosystemic shunt (TIPS) can effectively reduce the portal venous pressure and relieve the clinical complications related to portal hypertension. However, hepatic encephalopathy (HE) is still the main complication post TIPS. Studies have shown that patients over 65 years old with liver function reserve in Child-Pugh grade C are the high-HE-risk group post TIPS, and early TIPS treatment can benefit the survival of these high-risk patients. In this study, TIPS was used to treat 60 cases aged > 65 years old and liver function reserve in Child-Pugh grade C (decompensated liver cirrhosis) with esophagogastric variceal bleeding. The clinical results of 1-year was observed and the porto systemic gradient (PSG) was evaluated. The relationship between the incidence of HE and the PSG of patients with and without HE were compared to evaluate the effect of PSG on the incidence of HE.